Source	General Schedule
Body System	GENITO URINARY SYSTEM AND SEX HORMONES > SEX HORMONES AND MODULATORS OF THE GENITAL SYSTEM > PROGESTOGENS

Note

Restricted Benefit

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
13849XMPNP	MEDROXYPROGESTERONE medroxyprogesterone acetate 10 mg tablet, 30 (PI, CMI)	2	60	2	$27.21	$28.66	$31.60
	Available brands
	Raloveraa
	Proveraa * Additional charge for this brand is $13.40B	2	60	2	$40.61	$28.66	$45.00

Source	General Schedule
Body System	ANTINEOPLASTIC AND IMMUNOMODULATING AGENTS > ENDOCRINE THERAPY > HORMONES AND RELATED AGENTS

Restricted Benefit

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
13881NMP	MEDROXYPROGESTERONE medroxyprogesterone acetate 200 mg tablet, 60 (PI, CMI)	2	120	2	$183.13	$31.60	$31.60
	Available brands
	Provera

Source	General Schedule
Body System	GENITO URINARY SYSTEM AND SEX HORMONES > SEX HORMONES AND MODULATORS OF THE GENITAL SYSTEM > PROGESTOGENS

Restricted Benefit

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
13928CMP	MEDROXYPROGESTERONE medroxyprogesterone acetate 10 mg tablet, 100 (PI, CMI)	2	200	2	$59.27	$31.60	$31.60
	Available brands
	Raloveraa
	Proveraa * Additional charge for this brand is $13.40B	2	200	2	$72.67	$31.60	$45.00

Source	General Schedule
Body System	GENITO URINARY SYSTEM AND SEX HORMONES > SEX HORMONES AND MODULATORS OF THE GENITAL SYSTEM > PROGESTOGENS

Note

Restricted Benefit

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
13956MMPNP	MEDROXYPROGESTERONE medroxyprogesterone acetate 5 mg tablet, 56 (PI, CMI)	2	112	2	$24.43	$25.88	$29.33
	Available brands
	Raloveraa
	Proveraa * Additional charge for this brand is $9.16B	2	112	2	$33.59	$25.88	$38.49

Source	General Schedule
Body System	ANTINEOPLASTIC AND IMMUNOMODULATING AGENTS > ENDOCRINE THERAPY > HORMONES AND RELATED AGENTS

Restricted Benefit

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
13961TMP	MEDROXYPROGESTERONE medroxyprogesterone acetate 250 mg tablet, 60 (PI, CMI)	2	120	2	$188.43	$31.60	$31.60
	Available brands
	Provera

Source	General Schedule
Body System	ANTINEOPLASTIC AND IMMUNOMODULATING AGENTS > ENDOCRINE THERAPY > HORMONES AND RELATED AGENTS

Restricted Benefit

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
14038WMP	MEDROXYPROGESTERONE medroxyprogesterone acetate 500 mg tablet, 30 (PI, CMI)	2	60	2	$188.43	$31.60	$31.60
	Available brands
	Provera

Source	General Schedule
Body System	ANTINEOPLASTIC AND IMMUNOMODULATING AGENTS > ENDOCRINE THERAPY > HORMONES AND RELATED AGENTS

Restricted Benefit

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
14067JMP	MEDROXYPROGESTERONE medroxyprogesterone acetate 100 mg tablet, 100 (PI, CMI)	2	200	2	$161.61	$31.60	$31.60
	Available brands
	Provera

Source	General Schedule
Body System	GENITO URINARY SYSTEM AND SEX HORMONES > SEX HORMONES AND MODULATORS OF THE GENITAL SYSTEM > HORMONAL CONTRACEPTIVES FOR SYSTEMIC USE

Note

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
14160GMPNP	MEDROXYPROGESTERONE medroxyprogesterone acetate 150 mg/mL injection, 1 mL syringe (PI, CMI)	1	1	1	$27.59	$29.04	$31.60
	Available brands
	Depo-Proveraa

Source	General Schedule
Body System	ANTINEOPLASTIC AND IMMUNOMODULATING AGENTS > ENDOCRINE THERAPY > HORMONES AND RELATED AGENTS

Restricted Benefit

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
2316XMP	MEDROXYPROGESTERONE medroxyprogesterone acetate 200 mg tablet, 60 (PI, CMI)	1	60	2	$96.64	$31.60	$31.60
	Available brands
	Provera

Source	General Schedule
Body System	GENITO URINARY SYSTEM AND SEX HORMONES > SEX HORMONES AND MODULATORS OF THE GENITAL SYSTEM > PROGESTOGENS

Note

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
2321EMPNP	MEDROXYPROGESTERONE medroxyprogesterone acetate 10 mg tablet, 30 (PI, CMI)	1	30	2	$20.33	$21.78	$25.23
	Available brands
	Raloveraa
	Proveraa * Additional charge for this brand is $6.70B	1	30	2	$27.03	$21.78	$31.93

Source	General Schedule
Body System	GENITO URINARY SYSTEM AND SEX HORMONES > SEX HORMONES AND MODULATORS OF THE GENITAL SYSTEM > PROGESTOGENS

Note

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
2323GMPNP	MEDROXYPROGESTERONE medroxyprogesterone acetate 5 mg tablet, 56 (PI, CMI)	1	56	2	$18.94	$20.39	$23.84
	Available brands
	Raloveraa
	Proveraa * Additional charge for this brand is $4.58B	1	56	2	$23.52	$20.39	$28.42

Source	General Schedule
Body System	GENITO URINARY SYSTEM AND SEX HORMONES > SEX HORMONES AND MODULATORS OF THE GENITAL SYSTEM > PROGESTOGENS

Restricted Benefit

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
2722GMP	MEDROXYPROGESTERONE medroxyprogesterone acetate 10 mg tablet, 100 (PI, CMI)	1	100	2	$36.36	$31.60	$31.60
	Available brands
	Raloveraa
	Proveraa * Additional charge for this brand is $6.70B	1	100	2	$43.06	$31.60	$38.30

Source	General Schedule
Body System	ANTINEOPLASTIC AND IMMUNOMODULATING AGENTS > ENDOCRINE THERAPY > HORMONES AND RELATED AGENTS

Restricted Benefit

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
2725KMP	MEDROXYPROGESTERONE medroxyprogesterone acetate 100 mg tablet, 100 (PI, CMI)	1	100	2	$86.39	$31.60	$31.60
	Available brands
	Provera

Source	General Schedule
Body System	ANTINEOPLASTIC AND IMMUNOMODULATING AGENTS > ENDOCRINE THERAPY > HORMONES AND RELATED AGENTS

Restricted Benefit

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
2727MMP	MEDROXYPROGESTERONE medroxyprogesterone acetate 250 mg tablet, 60 (PI, CMI)	1	60	2	$99.16	$31.60	$31.60
	Available brands
	Provera

Source	General Schedule
Body System	ANTINEOPLASTIC AND IMMUNOMODULATING AGENTS > ENDOCRINE THERAPY > HORMONES AND RELATED AGENTS

Restricted Benefit

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
2728NMP	MEDROXYPROGESTERONE medroxyprogesterone acetate 500 mg tablet, 30 (PI, CMI)	1	30	2	$99.16	$31.60	$31.60
	Available brands
	Provera

Source	General Schedule
Body System	GENITO URINARY SYSTEM AND SEX HORMONES > SEX HORMONES AND MODULATORS OF THE GENITAL SYSTEM > HORMONAL CONTRACEPTIVES FOR SYSTEMIC USE

Note

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
3118DMPNP	MEDROXYPROGESTERONE medroxyprogesterone acetate 150 mg/mL injection, 1 mL vial (PI, CMI)
	Available brands
	Depo-Proveraa * Additional charge for this brand is $7.00B	1	1	1	$34.59	$29.04	$38.60